Enhancing return to work or school after a first episode of schizophrenia: the UCLA RCT of Individual Placement and Support and Workplace Fundamentals Module training.

BACKGROUND: This study evaluated in a rigorous 18-month randomized controlled trial the efficacy of an enhanced vocational intervention for helping individuals with a recent first schizophrenia episode to return to and remain in competitive work or regular schooling. METHODS: Individual Placement and Support (IPS) was adapted to meet the goals of individuals whose goals might involve either employment or schooling. IPS was combined with a Workplace Fundamentals Module (WFM) for an enhanced, outpatient, vocational intervention. Random assignment to the enhanced integrated rehabilitation program (N = 46) was contrasted with equally intensive clinical treatment at UCLA, including social skills training groups, and conventional vocational rehabilitation by state agencies (N = 23). All patients were provided case management and psychiatric services by the same clinical team and received oral atypical antipsychotic medication. RESULTS: The IPS-WFM combination led to 83% of patients participating in competitive employment or school in the first 6 months of intensive treatment, compared with 41% in the comparison group (p < 0.005). During the subsequent year, IPS-WFM continued to yield higher rates of schooling/employment (92% v. 60%, p < 0.03). Cumulative number of weeks of schooling and/or employment was also substantially greater with the IPS-WFM intervention (45 v. 26 weeks, p < 0.004). CONCLUSIONS: The results clearly support the efficacy of an enhanced intervention focused on recovery of participation in normative work and school settings in the initial phase of schizophrenia, suggesting potential for prevention of disability.

Improving Work Outcome in Supported Employment for Serious Mental Illness: Results From 2 Independent Studies of Errorless Learning.

Background: Heterogeneity in work outcomes is common among individuals with serious mental illness (SMI). Objective: In 2 studies, we sought to examine the efficacy of adding errorless learning, a behavioral training intervention, to evidence-based supported employment to improve SMI work outcomes. Work behavior problems were targeted for intervention. We also explored associations between early work behavior and job tenure. Methods: For both studies (VA: n = 71; community mental health center: n = 91), randomization occurred at the time of job obtainment with participants randomized (1:1) to either errorless learning plus ongoing supported employment or ongoing supported employment alone and then followed for 12 months. Dependent variables included job tenure, work behavior, and hours worked and wages earned per week. For the primary intent-to-treat analyses, data were combined across studies. Results: Findings revealed that participants in the errorless learning plus supported employment group stayed on their jobs significantly longer than those in the supported employment alone group (32.8 vs 25.6 wk). In addition, differential treatment effects favoring errorless learning were found on targeted work behavior problems (50.5% vs 27.4% improvement from baseline to follow-up assessment). There were no other differential treatment effects. For the prediction analyses involving work behavior, social skills explained an additional 18.3% of the variance in job tenure beyond levels of cognition, symptom severity, and past work history. Conclusions: These data support errorless learning as an adjunctive intervention to enhance supported employment outcomes and implicate the relevance of workplace social difficulties as a key impediment to prolonged job tenure.

El entrenamiento en habilidades sociales en la esquizofrenia / Social skills training for schizophrenia

El entrenamiento en habilidades sociales representa un conjunto de procedimientos de intervención que implica la utilización de principios y técnicas de modificación de conducta para la adquisición de experiencias básicas de aprendizaje. Su objetivo principal es facilitar el desarrollo de un repertorio de comportamientos dirigidos a permitir a una persona vivir de forma independiente y ha sido aplicado en el tratamiento de la esquizofrenia y de otros trastornos mentales graves. En este trabajo realizamos una revisión de la eficacia de este tipo de intervenciones mediante el estudio de los metaanálisis y ensayos clínicos aleatorizados, analizando los avances más recientes, sus ventajas y limitaciones. Como parte del tratamiento psicosocial y multidimensional de la esquizofrenia debatimos sobre la elección y los tipos de entrenamiento que mejores resultados han obtenido y sobre otros que están aportando importantes adaptaciones o aplicaciones de estas habilidades a diferentes ámbitos de la vida diaria

Social skills training involves a set of interventional procedures including behavior modification principles and techniques that lead to the acquisition of basic learning experiences. Its main objective is to facilitate the development of a code of conduct aimed at enabling people to live independently; it has been applied in the treatment of schizophrenia and other serious mental disorders. We review the efficacy of such interventions following meta-analyses and randomized clinical trials, and analyzing advantages and disadvantages of recent developments. We discuss the types of training that have achieved the best results and those contributing to their application and/or adaptation to different areas of daily life as part of the multidimensional and psychosocial treatment of schizophrenia

A demonstration project involving peers as providers of evidence-based, supported employment services.

OBJECTIVE: The present demonstration project involved development of a training program designed to teach recovering consumers employed as peer advocates how to provide evidence-based supported employment services to consumers with severe mental illness. METHODS: A training curriculum was developed to teach the core competencies of the Individual Placement and Support (IPS) model of supported employment. Three peers participated in training and provided work outcome data from their caseloads. Assessments were conducted of peers' competence in implementing IPS and effectiveness in promoting job placements. Peer competency was assessed by the following: (a) a formal IPS fidelity review performed by two external reviewers to evaluate service implementation, and (b) the Kansas Employment Specialist Job Performance Evaluation, an objective measure of employment specialist attitudes and skills. Program efficacy was assessed by examining the number of job placements and corresponding tenure. RESULTS: The fidelity review revealed that peers met IPS standards of implementation on 7 of 14 items assessing service delivery. The Kansas scale results revealed attitudes to be a relative strength and job performance competency ratings fell in the average to above average range across skill areas assessed (e.g., vocational assessment, job development). Thirty-three percent of consumers from the peers' caseloads got competitive jobs; mean tenure was 26.1 weeks. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: This demonstration project provides a starting point for future efforts aimed at expanding the role of peers as providers of evidence-based mental health services and provides a measured degree of optimism that this is a realistic, attainable goal.

Outcomes of the Chinese Basic Conversation Skill Module (CBCSM) for people with schizophrenia having mild to moderate symptoms and dysfunction in Hong Kong.

Abstract This study tested the effectiveness of a culturally adapted Chinese Basic Conversation Skill Module (CBCSM) for Hong Kong Chinese with schizophrenia. A total of 106 participants with schizophrenia who had mild to moderate levels of symptoms and dysfunction were recruited between January 2004 and September 2005. After random allocation, 35 participants were assigned to the CBCSM group with skill generalization training (SGT), 35 participants were assigned to the CBCSM group without SGT, and 36 participants were assigned to the placebo group. All participants were assessed by a blind rater at baseline, 5 weeks after commencement of skills training, and 3 and 6 months after completion of skills training on conversation skill mastery, subjective personal well being, and self esteem. After 15 sessions of intervention, the CBCSM group with SGT and the CBCSM group outperformed the placebo group in social skills. At the 6-month follow-up, social skill of CBCSM group with SGT was better than the CBCSM group and the placebo group. CBCSM with SGT was found to be effective in improving conversation skill of people with schizophrenia in Hong Kong. This combined strategy was also shown to be better than mere application of CBCSM in helping conversation skill mastery.

Attention shaping: a reward-based learning method to enhance skills training outcomes in schizophrenia.

Disturbances in sustained attention commonly interfere with the ability of persons with schizophrenia to benefit from evidence-based psychosocial treatments. Cognitive remediation interventions have thus far demonstrated minimal effects on attention, as have medications. There is thus a gap between the existence of effective psychosocial treatments and patients' ability to effectively engage in and benefit from them. We report on the results of a multisite study of attention shaping (AS), a behavioral intervention for improving attentiveness and learning of social skills among highly distractible schizophrenia patients. Patients with chronic schizophrenia who were refractory to skills training were assigned to receive either the UCLA Basic Conversation Skills Module (BCSM) augmented with AS (n = 47) or in the standard format (n = 35). AS, a reward-based learning procedure, was employed to facilitate patients' meeting clearly defined and individualized attentiveness and participation goals during each session of a social skills training group. Primary outcome measures were observational ratings of attentiveness in each session and pre- and post-BCSM ratings of social skill and symptoms. Patients receiving social skills training augmented with AS demonstrated significantly more attentiveness in group sessions and higher levels of skill acquisition; moreover, significant relationships were found between changes in attentiveness and amount of skills acquired. Changes in attentiveness were unrelated to level or change in antipsychotic medication dose. AS is an effective example of supported cognition, in that cognitive abilities are improved within the environmental context where the patient is experiencing difficulty, leading to gains in both attention and functional outcome.

Errorless learning for training individuals with schizophrenia at a community mental health setting providing work experience.

The effects of errorless learning (EL) on work performance, tenure, and personal well-being were compared with conventional job training in a community mental health fellowship club offering 12-week time-limited work experience. Participants were 40 clinically stable schizophrenia and schizoaffective disorder outpatients randomly assigned to EL vs conventional instruction (CI) at a thrift-type clothing store. EL participants received training on how to perform their assigned job tasks based on principles of EL, such as error reduction and automation of task performance. CI participants received training common to other community-based entry-level jobs that included verbal instruction, a visual demonstration, independent practice, and corrective feedback. Participants were scheduled to work 2 hours per week for 12 weeks. For both groups, job training occurred during the first 2 weeks at the worksite. Work performance (assessed using the Work Behavior Inventory, WBI) and personal well-being (self-esteem, job satisfaction, and work stress) were assessed at weeks 2, 4, and 12. Job tenure was defined as the number of weeks on the job or total number of hours worked prior to quitting or study end. The EL group performed better than the CI group on the Work Quality Scale from the WBI, and the group differences were relatively consistent over time. Results from the survival analyses of job tenure revealed a non-significant trend favoring EL. There were no group differences on self-esteem, job satisfaction, or work stress. The findings provide modest support for the extensions of EL to community settings for enhancing work performance.

Stress and coping responses to a natural disaster in people with schizophrenia.

Investigations of how individuals with schizophrenia differ from non-patients in their responses to stressful life events are subject to the criticism that any between-group differences might merely reflect differences in the types of stressful events that each group experiences. This report presents new analyses of data collected from schizophrenia patients (n=96), bipolar disorder patients (n=18), and healthy controls (n=18) immediately after the Northridge Earthquake that struck Southern California in 1994, a natural experiment that confronted all groups with the same stressful event. Participants completed the Impact of Events Scale (IES; [Horowitz, M.J., Wilner, N., Alvarez, W., 1979. Impact of Events Scale. A measure of subjective stress. Psychosomatic Medicine 41, 209-218]) at 1 week and 5 weeks post-earthquake. At the 5-week follow-up, measures of coping, social support, and self-esteem were also completed. Both patient groups reported higher IES avoidance symptoms than controls immediately after the earthquake. The schizophrenia group also reported lower approach coping, self-esteem, and social support than controls, with the bipolar group reporting intermediate levels. Within the schizophrenia group, higher levels of avoidance coping predicted higher residual stress symptoms at follow-up. Results support the validity of prior reports of altered responses to stressful life events in schizophrenia and demonstrate the clinical relevance of individual differences in coping among affected individuals.

Neurocognitive correlates of recovery from schizophrenia.

UNLABELLED: BACKGROUND. Evidence has mounted that some patients with schizophrenia experience remission of symptoms and restoration of social and vocational functioning. The purpose of this study was to identify neurocognitive variables associated with recovery from schizophrenia. METHOD: Twenty-eight patients diagnosed with DSM-IV schizophrenia or schizoaffective disorder and who met our operational definition of recovery from schizophrenia underwent a battery of neurocognitive tests. These subjects were matched with schizophrenia patients who did not meet recovery criteria ('non-recovered') and with normal controls. RESULTS: On tests of executive functioning, verbal fluency and verbal working memory, recovered subjects performed significantly better than non-recovered subjects and were comparable to normal controls. Patient groups did not differ on a test that assessed early visual processing, but both groups performed significantly worse than normal controls. CONCLUSIONS: Three measures of frontal lobe functioning appear to be neurocognitive domains associated with recovery from schizophrenia. These findings help narrow the search for targets for cognitive remediation that may have implications for improving community functioning.

Extensions of errorless learning for social problem-solving deficits in schizophrenia.

OBJECTIVE: There is a clear need to develop psychosocial rehabilitation methods that compensate for neurocognitive deficits common to persons with severe and persistent mental illness. Errorless learning, a compensatory training intervention, has been successful in teaching entry-level job tasks. However, errorless learning's applicability to broader, more complex functions is unknown. The present study tested the extension of errorless learning for deficits in social problem-solving skills in patients with schizophrenia. METHOD: Sixty clinically stable outpatients with schizophrenia or schizoaffective disorder were stratified by gender and level of memory impairment before being randomly assigned to one of two training programs: errorless learning or symptom management. Groups were matched for training time, format and structure of training, and types of teaching aids used. Social problem-solving ability, measured by the Assessment of Interpersonal Problem-Solving Skills, was assessed at baseline, within 2 days of training completion, and after 3 months. Dependent measures were the scores for the receiving, processing, and sending skills areas from the Assessment of Interpersonal Problem-Solving Skills. RESULTS: A repeated-measures analysis of covariance was conducted for each dependent measure with baseline Assessment of Interpersonal Problem-Solving Skills score entered as a covariate. For all three skills, there was a significant training group effect favoring errorless learning. Durability of errorless learning training effects extended to the 3-month follow-up assessment for processing and sending skills but not receiving skills. CONCLUSIONS: Results support the extension of errorless learning to complex functions such as social problem-solving skills in the rehabilitation of persons with schizophrenia.

Maintenance treatment of schizophrenia with risperidone or haloperidol: 2-year outcomes.

OBJECTIVE: Most controlled studies comparing second-generation and conventional antipsychotics have focused on the acute treatment of schizophrenia. The authors compared symptom outcomes, side effects, and social adjustment in stable schizophrenia outpatients who received 2 years of maintenance treatment with risperidone or haloperidol. METHOD: This was a 2-year, randomized, double-blind comparison of 6 mg of risperidone versus haloperidol in 63 patients with stabilized DSM-IV schizophrenia. Study patients also received 15 months of standard behavioral skills training or enhanced training with a case manager who promoted patients' use of their skills in the community. RESULTS: The risk of psychotic exacerbations and the risk of leaving the study were similar for both drug treatment groups. However, patients who received both risperidone and the enhanced community-based skills training were more likely to remain in the study than those in the other treatment groups. Patients demonstrated significant improvement in score on the Brief Psychiatric Rating Scale over time with both medications. There were no between-group differences in cluster scores for thought disturbance, hostile-suspiciousness, and withdrawal-retardation. A significant between-group difference favoring risperidone was found for the anxious-depression cluster. Risperidone resulted in significantly greater reductions in tremor and akathisia and greater improvements in most items on the SCL-90-R. CONCLUSIONS: When compared with patients given a low dose of haloperidol, risperidone-treated patients experienced similar improvements in positive and negative symptoms and similar risks of psychotic exacerbations. However, risperidone-treated patients appeared to feel subjectively better, as indicated by less anxiety and depression and fewer extrapyramidal side effects.

Applications of errorless learning for improving work performance in persons with schizophrenia.

OBJECTIVE: Until recently, few training methods used in the psychosocial rehabilitation of persons with schizophrenia have taken into account the neurocognitive deficits common to this illness. The present study tested a training method called errorless learning (which theoretically compensates for neurocognitive impairments) for efficacy at teaching entry-level job tasks to persons with serious and persistent mental illness. METHOD: Sixty-five unemployed, clinically stable outpatients with schizophrenia or schizoaffective disorder were randomly assigned to training by means of either errorless learning or conventional instruction for two entry-level job tasks (index card filing and toilet tank assembly). Training was conducted in small groups of four subjects for 90-120 minutes in a simulated workshop. Efficacy-as measured by accuracy, speed, and overall productivity-was assessed immediately after training and at a 3-month follow-up evaluation. RESULTS: Significant group differences in accuracy that favored errorless learning were found on both job tasks. In terms of productivity, the errorless learning group was superior to the conventional instruction group on the card filing task, and differences for the tank assembly task approached significance. There were no significant group differences in speed. Both groups showed significant drops in accuracy and productivity on the tank assembly task from immediately after training to the 3-month follow-up evaluation; performance levels were more stable for both groups on the card filing task. CONCLUSIONS: Errorless learning appears to be a useful training method for establishing introductory high levels of performance in the work rehabilitation of persons with schizophrenia. Future studies may wish to test its long-term durability by embedding it within supported employment programs.

In vivo amplified skills training: promoting generalization of independent living skills for clients with schizophrenia.

In Vivo Amplified Skills Training, IVAST, functions to bridge the gap between clinic-based skills training and use of social and independent living skills in everyday life for persons with schizophrenia and other serious and persistent mental illness. IVAST utilizes a specialist case manager who provides individualized, community-based teaching using behavioral techniques to promote clients' use of skills that were learned in classroom group sessions. The IVAST trainer also liaises with the client's psychiatrist and other clinic-based staff, family members, and community agencies to create opportunities, encouragement and reinforcement for the client's independent use of skills in the community. The aim of IVAST is to accelerate autonomous functioning of persons with mental disabilities in the community and thereby reduce their dependency on case managers and other therapists. To the extent that IVAST can empower clients to solve their own problems and attain their personal goals, enduring improvements in social role functioning and quality of life should ensure. A controlled study of IVAST has documented improvements in social adjustment when behavioral learning techniques are employed in the community settings of the clients. An IVAST case study is presented to illustrate the community-based use of medication management, symptom management, and social problem solving in the attainment of personally relevant goals. Obstacles to success of IVAST may derive from deficits in personal motivation, family involvement, community support, financial resources, premorbid functioning, and medication compliance.

A controlled trial of cognitive remediation in schizophrenia.

A randomized, controlled trial of a 3-month cognitive remediation program was examined for its efficacy at ameliorating deficits in social and emotion perception in 42 hospitalized patients with schizophrenia. Generalization of training effects to attention, memory, and executive functioning was also examined. The program included an eclectic mix of self-instruction, memory enhancement, inductive reasoning, and compensatory training procedures, while the control condition included participation in a leisure group that was matched to the experimental group for staff involvement time. Patient care management, including type and dose of antipsychotic medication, remained constant throughout the study period. The results indicated that the cognitive training program improved emotion perception, with some evidence of generalization to measures of executive functioning; other areas of neurocognitive functioning were largely unaffected. While cognitive training programs may improve targeted areas of neurocognitive processing, broad generalization effects to domains outside those targeted for intervention are not likely concomitants.

The neurocognitive effects of low-dose haloperidol: a two-year comparison with risperidone.

BACKGROUND: Neurocognitive deficits are core features of schizophrenia that are linked to functional outcome for the disorder. Recent studies and reviews have concluded that newer antipsychotic medications are better for neurocognitive deficits than conventional antipsychotic medications; however, one difficulty in interpreting this literature is that the comparisons have mainly been with high doses of conventional medications. This study examined the neurocognitive effects of low-dose haloperidol compared with risperidone over a 2-year period. METHODS: Sixty-two patients were randomly assigned to medication (starting at 6 mg of each medication) and administered neurocognitive batteries six times over the course of follow-up. At 6 months, the mean dose of haloperidol was 5.0 mg, and the mean dose of risperidone was 6.0 mg. Neurocognitive data were reduced into cluster scores and a global summary score. RESULTS: We found no significant overall differences in treatment effects on the cluster scores or the global score. The global score revealed a significant group by time interaction, reflecting the fact that the haloperidol group tended to improve initially and then stay stable, whereas the risperidone group improved more gradually over the follow-up period. CONCLUSIONS: This study did not provide support for neurocognitive advantages of a newer antipsychotic medication over a low-dose conventional medication. We speculate that conventional medications may have neurocognitive benefits at low doses that are neutralized or reversed at higher doses.

Supplementing clinic-based skills training with manual-based community support sessions: effects on social adjustment of patients with schizophrenia.

OBJECTIVE: Although skills training is a validated psychosocial treatment for schizophrenia, generalization of the skills to everyday life has not been optimal. This study evaluated a behaviorally oriented method of augmenting clinic-based skills training in the community with the aim of improving opportunities, encouragement, and reinforcement for outpatients to use their skills in their natural environment. METHOD: Sixty-three individuals with schizophrenia were randomly assigned to 60 weeks of clinic-based skills training alone or of clinic-based skills training supplemented with manual-based generalization sessions in the community. Patients were also randomly assigned to receive either haloperidol or risperidone. Therapists' fidelity to the manuals was measured. Patients' acquisition of the skills from pre- to posttraining was evaluated. The primary outcome measures were the Social Adjustment Scale-II and the Quality of Life Scale. RESULTS: Seventy-one percent of the patients completed the trial. Only six participants experienced psychotic exacerbations during the trial. There was no evidence of a differential medication effect on social functioning. Social functioning improved modestly in both psychosocial conditions over time; participants who received augmented skills training in the community showed significantly greater and/or quicker improvements. CONCLUSIONS: Given judicious and effective antipsychotic medication that limited exacerbations to less than 10% during the trial, a wide range of outpatients with schizophrenia demonstrated substantial learning of illness management and social skills in the clinic. When clinic-based skills training was augmented by in vivo training and consultation, transfer of the skills to everyday life was enhanced. These benefits were established regardless of the medications prescribed.